Before observing the two lights on the piers, the members of the bridge crew had to conduct the vessel by radar. The effective range of the lights was limited in fog and did not allow approach by visual observation. The range of the lights on the east and west piers complies with the beaconage service standards provided by the Canadian Coast Guard. Planning and timing are essential components for the success of any landing or docking operation. Because the vessel was steering 193G instead 190G, the approach occurred towards the head of the west pier instead of towards the centre of the harbour entrance. The master ordered the rudder angle increased, but this compensation was not deemed adequate. To bring the vessel back to the planned trajectory, a course alteration to port was ordered, but the delay in performing the course alteration contributed to causing the vessel to drift more towards the west pier. Because the main deck is covered, the side is high, and thus the ferry is subject to being driven by the wind. The navigator must take this into account. Near the entrance to the harbour, the main engines were stopped to minimize damage. The stiff breeze out of the east-south-east blowing abeam the vessel also contributed to driving the vessel toward the west pier. In adopting the International Safety Management Code on 4 November 1993, the International Maritime Organization (IMO) urged companies to implement a safety management system at all levels of the company, both at sea and ashore. As the Code does not come into force until June 1998, the IMO can at present only promote the Code. Safety management serves, in part, to define and establish written instructions for ensuring that the persons designated to perform tasks on board ships can discharge them. Because of the presence of fog in the approaches, a seaman helmsman was already at the helm when the crew was dispatched to the deck for docking. Instead of asking the second officer to replace the seaman helmsman at the helm, as was current practice on board, it was decided to keep the seaman helmsman at the helm because it was felt that he knew the vessel better than the second officer. There were no written instructions concerning crew members' assignments and roles. The decision to leave the seaman helmsman at the helm was made on the spur of the moment, on the assumption that the occasional seaman helmsman could perform the task of helmsman. Given the height of the tide at the time of the accident, the tetrapods were submerged by at least 9 m of water at the harbour entrance while the draught of the rail ferry was only 5 m. The GEORGES ALEXANDRE LEBEL therefore had an under-keel clearance of about 4 m. The presence of scoring on the side indicates that the rail ferry did not strike one or more tetrapods on the bottom but rather those forming part of the head of the west pier.Analysis Before observing the two lights on the piers, the members of the bridge crew had to conduct the vessel by radar. The effective range of the lights was limited in fog and did not allow approach by visual observation. The range of the lights on the east and west piers complies with the beaconage service standards provided by the Canadian Coast Guard. Planning and timing are essential components for the success of any landing or docking operation. Because the vessel was steering 193G instead 190G, the approach occurred towards the head of the west pier instead of towards the centre of the harbour entrance. The master ordered the rudder angle increased, but this compensation was not deemed adequate. To bring the vessel back to the planned trajectory, a course alteration to port was ordered, but the delay in performing the course alteration contributed to causing the vessel to drift more towards the west pier. Because the main deck is covered, the side is high, and thus the ferry is subject to being driven by the wind. The navigator must take this into account. Near the entrance to the harbour, the main engines were stopped to minimize damage. The stiff breeze out of the east-south-east blowing abeam the vessel also contributed to driving the vessel toward the west pier. In adopting the International Safety Management Code on 4 November 1993, the International Maritime Organization (IMO) urged companies to implement a safety management system at all levels of the company, both at sea and ashore. As the Code does not come into force until June 1998, the IMO can at present only promote the Code. Safety management serves, in part, to define and establish written instructions for ensuring that the persons designated to perform tasks on board ships can discharge them. Because of the presence of fog in the approaches, a seaman helmsman was already at the helm when the crew was dispatched to the deck for docking. Instead of asking the second officer to replace the seaman helmsman at the helm, as was current practice on board, it was decided to keep the seaman helmsman at the helm because it was felt that he knew the vessel better than the second officer. There were no written instructions concerning crew members' assignments and roles. The decision to leave the seaman helmsman at the helm was made on the spur of the moment, on the assumption that the occasional seaman helmsman could perform the task of helmsman. Given the height of the tide at the time of the accident, the tetrapods were submerged by at least 9 m of water at the harbour entrance while the draught of the rail ferry was only 5 m. The GEORGES ALEXANDRE LEBEL therefore had an under-keel clearance of about 4 m. The presence of scoring on the side indicates that the rail ferry did not strike one or more tetrapods on the bottom but rather those forming part of the head of the west pier. The company had not implemented a safety management system. The seaman at the helm had not received adequate training to perform docking operations. The course alteration was not performed in time to avoid the head of the west pier. During the approach, the wind drove the vessel towards the head of the west pier at the harbour entrance. The effective range of the pier lights made it impossible to approach by visual observation.Findings The company had not implemented a safety management system. The seaman at the helm had not received adequate training to perform docking operations. The course alteration was not performed in time to avoid the head of the west pier. During the approach, the wind drove the vessel towards the head of the west pier at the harbour entrance. The effective range of the pier lights made it impossible to approach by visual observation. The GEORGES ALEXANDRE LEBEL struck the head of the west pier because steering and main engine manoeuvres were not performed in time. The company did not have any directives respecting crew members' assignments and roles. In this occurrence, the seaman helmsman could not perform his steering duties.Causes and Contributing Factors The GEORGES ALEXANDRE LEBEL struck the head of the west pier because steering and main engine manoeuvres were not performed in time. The company did not have any directives respecting crew members' assignments and roles. In this occurrence, the seaman helmsman could not perform his steering duties.